Citation Nr: 22019980 Decision Date: 04/03/22 Archive Date: 04/03/22 DOCKET NO. 16-46 003A DATE: April 3, 2022 ORDER Entitlement to a compensable initial disability rating for service-connected hypertension is denied. Entitlement to a compensable initial disability rating for service-connected bilateral hearing loss denied. Entitlement to an initial disability rating in excess of 10 percent for service-connected diabetic peripheral neuropathy of the sciatic nerve of the left lower extremity is denied. Entitlement to a separate disability rating of 10 percent, but no higher, for service-connected diabetic peripheral neuropathy of the femoral nerve of the left lower extremity from July 7, 2021 is granted. REMANDED Entitlement to service connection for a bilateral eye disability is remanded. FINDINGS OF FACT 1. From the date of service connection, the Veteran's hypertension has required continuous medication for control and is manifested by diastolic pressure predominantly 100 or less and systolic pressure predominantly 160 or less. 2. From the date of service connection, the Veteran's bilateral hearing loss has been productive of no worse than Level I hearing impairment in the right ear and Level I hearing impairment in the left ear. 3. From the date of service connection, the Veteran's diabetic peripheral neuropathy of the sciatic nerve of the left lower extremity is manifested by paresthesias and numbness in the left foot and leg, which more nearly approximates mild incomplete paralysis of the sciatic nerve. 4. From July 7, 2021, the Veteran's service-connected diabetic peripheral neuropathy of the left femoral nerve is manifested by paresthesia and numbness, which more nearly approximates mild incomplete paralysis of the anterior crural (femoral) nerve. CONCLUSIONS OF LAW 1. The criteria for entitlement to a compensable initial disability rating for hypertension have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.104, Diagnostic Code (DC) 7101. 2. The criteria for a compensable initial disability rating for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.85, DC 6100. 3. The criteria for an initial disability rating in excess of 10 percent for service-connected diabetic peripheral neuropathy of the sciatic nerve of the left lower extremity have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.124a, DC 8520. 4. The criteria for a separate 10 percent disability rating for diabetic peripheral neuropathy of the femoral nerve of the left lower extremity from July 7, 2021 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.124a, DC 8526. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1984 to July 1999 and October 2004 to October 2012. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO), which granted service connection for hypertension and bilateral hearing loss and assigned noncompensable disability ratings to each, effective from November 1, 2012. The rating decision also granted service connection for diabetic peripheral neuropathy of the left lower extremity and assigned a 10 percent disability rating from November 1, 2012. In addition, the rating decision denied service connection for a bilateral eye disability. The Veteran filed a notice of disagreement (NOD) in February 2014 and a statement of the case (SOC) was issued in August 2016. He perfected a timely appeal in September 2016. In September 2019, the Veteran presented sworn testimony during a personal hearing in Washington D.C., which was chaired by the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the Veteran's VA claims file. In a March 2020 Board decision, the claims were remanded for further evidentiary development. As to the increased rating claims, review of the record reflects substantial compliance with the Board's Remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). A supplemental statement of the case (SSOC) was issued in November 2020. The Veteran's VA claims file has been returned to the Board for further appellate proceedings. Subsequent to the issuance of the November 2020 SSOC, VA examination and treatment records were added to the VA claims file. In November 2021, the Veteran submitted a written waiver of RO consideration of this evidence. This waiver is contained in the VA claims file. See 38 C.F.R. §§ 19.9, 20.1304(c). In an August 2021 rating decision, the RO granted service connection for diabetic peripheral neuropathy of the left femoral nerve and evaluated the disability with the already service-connected partially ruptured left hamstring with muscular defect, which was assigned a 10 percent disability rating. As the diabetic peripheral neuropathy of the left femoral nerve rating was assigned during the appeal of the claim of entitlement to an increased disability rating for diabetic peripheral neuropathy of the left lower extremity, the Board finds that the femoral nerve rating is properly before the Board. The matter will therefore be considered herein. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. If two disability ratings are potentially applicable, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In view of the number of atypical instances, it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. 38 C.F.R. § 4.21. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. Any reasonable doubt regarding the degree of disability is resolved in favor of the Veteran. 38 C.F.R. §§ 3.102, 4.3. When the appeal arises from an initial assigned rating, consideration must be given to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). However, staged ratings are also appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, analysis in this decision has therefore been undertaken with consideration of the possibility that different ratings may be warranted for different time periods as to the pending claims. In all cases, the Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. Barr, at 308 (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-12 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (holding that the Board has the "authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence"). The Board has considered all evidence of record as it bears on the issue before it. See 38 U.S.C. § 7104(a) ("Decisions of the Board shall be based on the entire record in the proceeding and upon consideration of all evidence and material of record"); 38 U.S.C. § 5107(b) ("Secretary shall consider all information and lay and medical evidence of record in a case"). Although the Board has an obligation to provide reasons and bases supporting these decisions, there is no need to discuss, in detail, the extensive evidence of record. The Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the Veteran's appeal. 1. Entitlement to a compensable disability rating for service-connected hypertension. The Veteran's hypertension has been assigned a noncompensable evaluation under 38 C.F.R. § 4.104, DC 7101. Under that DC, a 10 percent evaluation is warranted where diastolic blood pressure is predominantly 100 or more, or systolic blood pressure is predominantly 160 or more, or when an individual with a history of diastolic blood pressure predominantly 100 or more requires continuous medication for control. A 20 percent evaluation is warranted where diastolic blood pressure is predominantly 110 or more, or systolic blood pressure is predominantly 200 or more. A 40 percent evaluation is warranted where diastolic pressure is predominantly 120 or more, and a 60 percent evaluation is warranted where diastolic blood pressure is predominantly 130 or more. 38 C.F.R. § 4.104. The term "predominant" is not defined in the rating criteria. Merriam-Webster defines predominant to mean "being most frequent or common." See, e.g., "predominant," Merriam-Webster.com Online Dictionary, https://www.merriam-webster.com/dictionary/predominant. As described above, the Veteran's service-connected hypertension was assigned a noncompensable (zero percent) rating under DC 7101 from November 1, 2012. See the rating decision dated October 2013. For the reasons set forth below, the Board finds that a compensable initial disability rating is not warranted. The Veteran's service treatment records (STRs) include numerous blood pressure readings and a diagnosis of hypertension. STRs dated in November 2009 document a prescription of Lisinopril to manage the Veteran's hypertension symptoms. The Veteran had numerous blood pressure readings recorded during his two periods of active duty service (June 1984 to July 1999 and October 2004 to October 2012). However, his systolic blood pressure r was never documented to have reached 160, and was predominantly between 115 and 135. The Veteran's diastolic blood pressure was never documented to have reached 100 or greater, and was predominantly between 70 and 82. The Veteran was afforded a VA examination in September 2012 at which time the examiner confirmed a continuing diagnosis of hypertension. The examiner noted that the Veteran is prescribed medication for his hypertension; specifically, Lisinopril. The examiner documented current blood pressure readings of 118/92, 116/94, and 118/96. The examiner did indicate that the Veteran had a history of diastolic blood pressure elevation to predominantly 100 or more. However, the examiner did not describe the frequency and severity of the Veteran's diastolic blood pressure elevation. The examiner reported that the Veteran's hypertension has no impact on his ability to work. VA treatment records include numerous blood pressure readings dating through 2021. Notably, the Veteran's systolic blood pressure did not reach 160 and his diastolic blood pressure did not reach 100 in any of the documented blood pressure readings. The Veteran was afforded a VA examination in June 2021 at which time the VA examiner noted the Veteran's report that his blood pressure medications were increased two years ago because of uncontrolled blood pressure. He was taking Lisinopril 5 mg daily, which was increased to 20 mg daily. The Veteran reported that his home blood pressure readings average between 116/77 to 129/78. The examiner reported that the Veteran does not have a history of diastolic blood pressure elevation to predominantly 100 or more. Current blood pressure readings were 130/73, 132/77, and 127/78. The examiner indicated that the Veteran's hypertension does not impact his ability to work. The evidence of record demonstrates that the Veteran's documented blood pressure readings show that his diastolic pressure has consistently been below 100, and his systolic pressure was predominantly below 160. This is consistent with the Veteran's reports of his home blood pressure readings. Review of medical records throughout the course of the appeal confirms the use of medication to control the Veteran's hypertension. However, the Board notes that the rating criteria for hypertension specifically contemplate the use of medication to ameliorate symptoms and that a higher rating may not be assigned based solely on the fact that the Veteran uses medication to treat his symptoms. McCarroll v. McDonald, 28 Vet. App. 267 (2016) (the Board did not err in failing to discount the ameliorative effects of blood pressure medication as the plain language of DC 7101 contemplates the effects of medications). The evidence of record further demonstrates that the Veteran's blood pressure readings do not more nearly approximate a history of diastolic pressure predominantly 100 or more that requires continuous medication for control. The Board recognizes that the September 2012 VA examiner indicated that the Veteran had a history of diastolic blood pressure at predominantly 100 or more. However, as indicated above, the examiner did not describe the frequency or severity of these blood pressure elevations, as was instructed in the examination report. Moreover, the examiner's finding is not supported in the medical evidence, which did not document a single diastolic reading at 100 or more. The September 2012 VA examiner's notation was also contradicted by the finding of the June 2021 VA examiner, who specifically indicated that the Veteran did not have a history of diastolic blood pressure at predominantly 100 or more. Accordingly, the Board finds that this notation by the September 2012 examiner is an outlier and is unsupported by the record. Thus, this aspect of the report is of low probative weight. The evidence therefore demonstrates that the Veteran's hypertension requires continuous medication; however, the probative evidence is persuasively against a finding that the Veteran has a history of diastolic pressure predominantly 100 or more. Under these circumstances, an initial compensable rating is not warranted for the Veteran's service-connected hypertension under the pertinent diagnostic criteria. 38 C.F.R. § 4.104, Diagnostic Code 7101. For the foregoing reasons, the Board finds that the Veteran's hypertension symptoms have not more nearly approximated the criteria for a compensable disability rating. The Board therefore concludes that the evidence substantially weighs against the claim and it is denied to that extent. 38 U.S.C. § 5107(b); see also Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc). 2. Entitlement to a compensable disability rating for service-connected bilateral hearing loss. As indicated above, the Veteran's service-connected bilateral hearing loss is assigned a noncompensable disability rating from November 1, 2012. The Veteran asserts entitlement to a compensable disability rating from the date of service connection. See the Board hearing transcript dated September 2019. As will be explained below, the resolution of this issue involves determining the levels of hearing acuity. Impairment of auditory acuity (hearing loss) is evaluated pursuant to the provisions set forth at 38 C.F.R. § 4.85. Under that regulation, an examination for hearing impairment must be conducted by a state-licensed audiologist and must include a controlled speech discrimination test (Maryland CNC) and a pure tone audiometry test. Examinations are to be conducted without the use of hearing aids. 38 C.F.R. § 4.85(a). To evaluate the degree of disability from defective hearing, the Rating Schedule establishes 11 auditory acuity levels from Level I, for essentially normal acuity, through Level XI, for profound deafness. These are assigned based on a combination of the percent of speech discrimination and the pure tone threshold average, as contained in a series of tables within the regulations. 38 C.F.R. § 4.85(b). The pure tone threshold average is the sum of the pure tone thresholds at 1000, 2000, 3000, and 4000 Hertz (Hz), divided by four. This average is used in all cases to determine the Roman numeral designation for hearing impairment from Table VI or VIA. 38 C.F.R. § 4.85(d). Table VII, Percentage Evaluations for Hearing Impairment, is used to determine the percentage evaluation by combining the Roman numeral designations for hearing impairment of each ear. The horizontal rows represent the ear having the better hearing and the vertical columns the ear having the poorer hearing. The percentage evaluation is located at the point where the row and column intersect. 38 C.F.R. § 4.85(e). In cases where impaired hearing is service-connected in only one ear, in order to determine the percentage evaluation from Table VII, the non-service-connected ear will be assigned a Roman Numeral designation for hearing impairment of I, subject to the provisions of 38 C.F.R. § 3.383. 38 C.F.R. § 4.85(f). The regulatory provisions also provide two additional circumstances under which alternative tables can be employed. One is where the pure tone thresholds of the frequencies of 1000, 2000, 3000, and 4000 Hz are 55 decibels or greater. The second is where pure tone thresholds are 30 decibels or less at frequencies of 1000 Hz and below, and are 70 decibels or more at 2000 Hz. See 38 C.F.R. § 4.86. In this matter, the Veteran was afforded a VA audiology examination in September 2012 at which time the examiner noted the following pure tone thresholds: HERTZ 1000 2000 3000 4000 Average RIGHT 40 35 35 25 34 LEFT 35 35 35 30 34 Average pure tone threshold was 34 decibels in the right ear with speech recognition ability of 100 percent. Average pure tone threshold was 34 decibels in the left ear with speech recognition ability of 96 percent. The examiner stated that the Veteran's bilateral hearing loss does impact the ordinary conditions of his daily life, including his ability to work; specifically, "[d]ifficulty hearing in noisy environments." Such examination findings translate to level I hearing in the right ear and level I hearing in the left ear. 38 C.F.R. § 4.85, Table VI. Applying Table VII, DC 6100, this equates to a noncompensable (zero percent) rating. A July 2019 private audiological evaluation noted the following pure tone thresholds: HERTZ 1000 2000 3000 4000 Average RIGHT 40 30 35 25 32.5 LEFT 35 30 35 30 32.5 Speech recognition scores were 100 percent in the right ear and 96 percent in the left ear. Although the July 2019 audiogram does not indicate that speech recognition scores were obtained using the Maryland CNC test, as required by 38 C.F.R. § 4.85(a), even assuming they were, the examination findings translate to level I hearing in the right ear and level I hearing in the left ear. 38 C.F.R. § 4.85, Table VI. Applying Table VII, DC 6100, this equates to a noncompensable (zero percent) rating. Another VA audiology examination was conducted in September 2020. The examiner documented the following pure tone thresholds: HERTZ 1000 2000 3000 4000 Average RIGHT 50 40 40 35 41.25 LEFT 45 45 40 35 41.25 Average pure tone threshold was 41.25 decibels in the right ear with speech recognition ability of 94 percent. Average pure tone threshold was 41.25 decibels in the left ear with speech recognition ability of 100 percent. The examiner stated that the Veteran's bilateral hearing loss does impact the ordinary conditions of his daily life, including his ability to work. The Veteran explained, "[m]ost people know that I have a hearing problem." He notifies people that, if they speak in a certain tone, he may not hear them. Such examination findings translate to level I hearing in the right ear and level I hearing in the left ear. 38 C.F.R. § 4.85, Table VI. Applying Table VII, DC 6100, this equates to a noncompensable (zero percent) rating. A June 2021 VA examination documented the following pure tone thresholds: HERTZ 1000 2000 3000 4000 Average RIGHT 45 40 45 40 43 LEFT 45 35 40 35 39 Average pure tone threshold was 43 decibels in the right ear with speech recognition ability of 96 percent. Average pure tone threshold was 39 decibels in the left ear with speech recognition ability of 96 percent. The examiner stated that the Veteran's bilateral hearing loss does impact the ordinary conditions of his daily life, including his ability to work. The examiner indicated that the Veteran has difficulty hearing female talkers or people with soft voices. He has an extremely difficulty time hearing with background noise. In his daily life, the Veteran tries to read lips, and asks people to repeat themselves. The Veteran further stated that he is unable to hear certain engine noises in a work environment. Such examination findings translate to level I hearing in the right ear and level I hearing in the left ear. 38 C.F.R. § 4.85, Table VI. Applying Table VII, DC 6100, this equates to a noncompensable (zero percent) rating. Accordingly, audiometric testing conducted during the course of the appeal, including for VA compensation purposes, indicates that a compensable rating is not warranted pursuant to DC 6100. 38 C.F.R. § 4.85. There is no audiological evidence of record to support a compensable disability rating for the Veteran's bilateral hearing loss disability. The Board therefore concludes that the evidence substantially weighs against the claim and it is denied to that extent. 38 U.S.C. § 5107(b); see also Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc). The Board in no way discounts the difficulties that the Veteran experiences as a result of his service-connected bilateral hearing loss disability. In this regard, it must be emphasized that the disability ratings for hearing impairment are derived by a mechanical application of the rating schedule to the numeric designation assigned after audiometry results are obtained. Hence, the Board must base its determination on the results of the pertinent and valid audiology studies. See Lendenmann, 3 Vet. App. at 345. In other words, the Board is bound by law to apply VA's rating schedule based on the Veteran's audiometry results. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Under these circumstances, the Board finds that the record presents no basis for assignment of higher initial ratings. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extraschedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. The Board finds that the rating criteria contemplate the Veteran's bilateral hearing loss disability. His hearing loss is manifested by decreased hearing acuity. A comparison between the level of severity and symptomatology of the Veteran's assigned rating with the established criteria found in the rating schedule shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology, including his difficulty hearing and understanding speech. The Board notes that this conclusion is consistent with the Court's holding in Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) ("[W]hen a claimant's hearing loss results in an inability to hear or understand speech or to hear other sounds in various contexts, those effects are contemplated by the schedular rating criteria"). The Board further finds that other than difficulty hearing or understanding speech, the record on appeal contains no evidence of other symptoms attributable to the service-connected hearing loss, such as dizziness, vertigo, or ear pain, not contemplated by the rating criteria. Because the rating criteria reasonably describe the claimant's disability level and symptomatology, the Veteran's disability picture is contemplated by the Rating Schedule, such that the assigned schedular noncompensable evaluation is, therefore, adequate, and no referral is required. Thun v. Peake, 22 Vet. App. 111, 115-116 (2008); VAOPGCPREC 6-96. The evidence does not show anything unique or unusual about the Veteran's bilateral hearing loss that would render the schedular criteria inadequate. 3. Entitlement to a disability rating in excess of 10 percent for service-connected diabetic peripheral neuropathy of the sciatic nerve of the left lower extremity. 4. Entitlement to a separate disability rating for diabetic peripheral neuropathy of the femoral nerve of the left lower extremity. Section 4.124a provides a schedule of ratings for diseases of the peripheral nerves. The Veteran's diabetic peripheral neuropathy of the left lower extremity is rated at 10 percent under DC 8520, which pertains to the sciatic nerve. Under DC 8520, mild incomplete paralysis warrants a 10 percent rating; moderate incomplete paralysis warrants a 20 percent rating; moderately severe incomplete paralysis warrants a 40 percent rating; severe incomplete paralysis, with marked muscular atrophy, warrants a 60 percent rating; and complete paralysis; the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost warrants a maximum 80 percent rating. As indicated above, the Veteran has also been separately service-connected for diabetic peripheral neuropathy of the femoral nerve of the left lower extremity. However, rather than assigning the Veteran a separate rating under DC 8526, which pertains to the femoral nerve, the RO determined that the peripheral neuropathy of the femoral nerve should be evaluated with his service-connected partially ruptured left hamstring with muscular defect based on the rating criteria of the predominant disability. See the rating decision dated August 2021. Under DC 8526, for incomplete paralysis of the femoral nerve, a 10 percent rating is warranted for mild paralysis, 20 percent for moderate paralysis, and 30 percent for severe incomplete paralysis. A 40 percent rating is warranted for complete paralysis of the quadriceps extensor muscles. There are five nerve branches in the lower extremities. Each branch has its separate and distinct functions. The sciatic branch includes the sciatic nerve, external popliteal nerve (common peroneal), musculocutaneous (superficial peroneal), anterior tibial nerve (deep peroneal), internal popliteal (tibial), and posterior tibial nerves. The femoral branch includes the anterior crural (femoral) and the internal saphenous nerves. The obturator, external cutaneous thigh, and illio-inguinal nerve branches only include one nerve each. The words "mild," "moderate," and "severe" are not defined in the VA Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." See 38 C.F.R. § 4.6. The term "incomplete paralysis," with peripheral nerve injuries, indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to the partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. See 38 C.F.R. § 4.124a, DCs 8510-8730. In this matter, the Veteran asserts entitlement to a higher disability rating for diabetic peripheral neuropathy of the left lower extremity. For the reasons set forth below, the Board finds that a disability rating in excess of 10 percent is not warranted for diabetic peripheral neuropathy of the sciatic nerve of the left lower extremity. However, the Board also finds that a separate disability rating of 10 percent, but no higher, is warranted for diabetic peripheral neuropathy of the femoral nerve of the left lower extremity from July 7, 2021. The Veteran was afforded a VA examination in September 2012 at which time the examiner confirmed a diagnosis of diabetic peripheral neuropathy of the left foot. The Veteran denied constant and intermittent pain in the left lower extremity. He endorsed mild paresthesias and mild numbness. There was no impairment of muscle strength. Sensation to light touch was decreased in the left foot and toes. There were no trophic changes of the left lower extremity. The Veteran's gait was normal. The examiner indicated that the Veteran exhibited moderate incomplete paralysis of the left posterior tibial nerve. The examiner opined that the Veteran's disability had no impact on his ability to work. In the October 2013 rating decision, the RO granted service connection for diabetic peripheral neuropathy of the left lower extremity and assigned a 10 percent disability rating under DC 8525 based upon mild incomplete paralysis of the posterior tibial nerve. Pursuant to the March 2020 Board Remand, the Veteran was afforded a VA examination in November 2020 at which time the examiner indicated that the Veteran did not exhibit any symptoms of neuropathy in the left lower extremity. Specifically, the examiner reported that the Veteran's muscle strength was intact and there was no muscle atrophy. Deep tendon reflexes were intact and sensation to light touch was normal. The Veteran's gait was normal. The examiner reported that there was no evidence of nerve impairment in the left lower extremity. The Veteran was afforded a VA examination in August 2021 at which time the examiner noted the Veteran's report of numbness and tingling in the left foot. The Veteran indicated that his symptoms are treated with medication. He denied pain in the left lower extremity. He endorsed mild paresthesias, as well as mild numbness. Muscle strength was intact in the left lower extremity. Deep tendon reflexes were normal. There was decreased sensation to light touch in the left foot and toes. Vibration sense and cold sensation were also decreased in the left foot and toes. There was no muscle atrophy or trophic changes. The examiner diagnosed the Veteran with mild incomplete paralysis of the sciatic nerve, as well as mild incomplete paralysis of the femoral nerve. The examiner indicated that the Veteran's diabetic neuropathy of the left lower extremity does impact his ability to work and estimated that the Veteran has lost between two to four weeks of work time in the last twelve months as a result of this disability. The examiner explained that the Veteran's disability affects his ability to stand or walk for long periods of time. As indicated above, in an August 2021 rating decision, the RO granted service connection for diabetic peripheral neuropathy of the femoral nerve of the left lower extremity, effective from July 7, 2021. The RO indicated that a separate disability rating was not warranted for involvement of the femoral nerve because, as the Veteran was previously granted service connection for partially ruptured left hamstring with muscular defect, VA regulations prohibit evaluation of muscle injuries separately from nerve paralysis if the muscle and nerves control the same functions. See the rating decision dated August 2021. The RO therefore evaluated the Veteran's peripheral neuropathy of the femoral nerve with his service-connected partially ruptured left hamstring with muscular defect and assigned a combined 10 percent disability rating from July 7, 2021. The RO also determined that the left lower extremity peripheral neuropathy of the sciatic nerve should be evaluated under DC 8520, instead of DC 8525, as previously rated. Based upon the evidence of record, set forth in pertinent part above, the Board finds that an initial rating in excess of 10 percent rating is not warranted for peripheral neuropathy of the sciatic nerve of the left lower extremity. The medical evidence demonstrates that the symptomatology associated with the Veteran's sciatic nerve involvement is characterized by paresthesias, numbness, and mild sensory impairment. There is no evidence of functional impairment such as muscle wasting, atrophy, weakness, or tremors in his lower extremities. The Board finds the Veteran's "wholly sensory" symptoms alone do not constitute evidence that is sufficient to characterize his service-connected radiculopathy of the left lower extremity as "moderate." The Veteran's symptoms do not approach the "average" or "medium" range and are best described as mild. The Board additionally finds that a separate 10 percent rating for involvement of the left femoral nerve under DC 8526 is warranted from the July 7, 2021, the date of the VA examination documenting femoral nerve involvement. DC 8526, which pertains to the anterior crural (femoral) nerve, directs that a 10 percent rating be assigned for mild incomplete paralysis of the femoral nerve. The evidence shows that impairment anterior crural (femoral) nerve was documented by the July 2021 VA examiner. A 10 percent rating for such is warranted as the Veteran experienced no greater than mild incomplete paralysis of nerves in the femoral branch. However, the evidence does not show involvement in the left femoral branch that is greater than mild in severity. The July 2021 examiner determined that the Veteran's disability picture in the left lower extremity indicated that the involvement of the femoral branch was no more severe than that of the sciatic branch. The Board notes that that prior VA examiners did not identify any impairment of the anterior crural (femoral) nerve branch. Nevertheless, the Board will afford weight to the July 2021 examiner's opinion that the involvement of the femoral branch manifests in the form of no greater than mild incomplete paralysis. Again, as the sciatic and femoral branches have their own separate and distinct functions, awarding separate compensable ratings for both the sciatic and femoral branches does not violate the rule against pyramiding. 38 C.F.R. § 4.14. Although it may be unclear as to which symptoms are attributable to the sciatic or femoral involvement, assigning separate ratings for both the sciatic and femoral nerves during the periods where there is involvement of both nerve branches will ensure that all the manifestations of the Veteran's left lower extremity paresthesias are being compensated; and the Board will afford weight to the opinions of the examiners as to the severity of each branch's involvement during these periods, rather than substitute its own medical judgment. Further, as the Veteran did not experience severe symptoms, or complete paralysis, related to the obturator, external cutaneous nerve of thigh, and ilio-inguinal nerve are not severe, he is not entitled to a separate rating for any of these nerve branches under DCs 8528, 8529, or 8530. Although the RO determined that the disability rating for the femoral nerve involvement should be combined with the rating for the service-connected partially ruptured left hamstring with muscular defect, the Board finds that this determination was made in error. The Board recognizes that a muscle injury rating cannot be combined with a peripheral nerve paralysis rating of the same body part unless the injuries affect entirely different functions. 38 C.F.R. § 4.55(a). However, in this case, the involvement of the sciatic and femoral nerves affects different functions of the left lower extremity than the partially ruptured left hamstring disability. Notably, VA examination findings as to the partially ruptured left hamstring disability noted the Veteran's report of a pulling sensation at the back of his leg during long runs or with lifting exercises. See the VA examination report dated April 1999; see also the rating decision dated October 1999. The examiner noted that motor function and sensation were intact. Id. Physical examination of the left lower extremity revealed a divot in the left thigh muscle just above the posterior aspect of the knee, consistent with a hamstring tendon injury. Id. The 10 percent rating originally assigned to the left hamstring disability was in no way intended to compensate for paresthesias, numbness, or sensory impairment of the left lower extremity. See the rating decision dated October 1999. As such, the Board finds that the sciatic and femoral nerve disabilities of the left lower extremity affect entirely different functions than the left hamstring disability. Separate ratings are therefore warranted. Accordingly, the assignment of a separate 10 percent rating for peripheral neuropathy of the femoral nerve of the left lower extremity is warranted from July 7, 2021. In sum, the Board has considered the entire record, including the Veteran's reported symptomatology and the objective clinical evidence. For the reasons set forth above, the Board finds that a disability rating in excess of 10 percent is not warranted for diabetic peripheral neuropathy of the sciatic nerve of the left lower extremity. The Board additionally finds that a separate 10 percent disability rating, but no higher, is warranted for diabetic peripheral neuropathy of the femoral nerve of the left lower extremity from July 7, 2021. REASONS FOR REMAND 1. Entitlement to service connection for a bilateral eye disability is remanded. The Veteran asserts entitlement to service connection for a bilateral eye disability to include glaucoma and diabetic retinopathy. See, e.g., the September 2019 Board hearing transcript. This claim was remanded in March 2020 in order to obtain a VA medical opinion to address current diagnosis and etiology of the Veteran's claimed bilateral eye disability. Pursuant to the Board remand, VA medical opinions were obtained in March 2020 in which the examiner determined that the claimed disability was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner reported, "[a]s of last examination November 6, 2012, diabetic retinopathy is not a current diagnosis. Diabetic retinopathy will repair with health improvement. Diabetic retinopathy from examination prior to November 6, 2012 can be considered improved to state that is no longer a diagnosis." The examiner continued, "[i]t is also possible that diabetic retinopathy can return if there is a change in status of systemic diabetes." In a separate March 2020 opinion, the VA examiner reported that the "Veteran has previously been monitored for glaucoma as a "glaucoma suspect". This is not a diagnosis of glaucoma." Unfortunately, it appears that the VA medical opinions were rendered without review of the Veteran's current VA treatment records, as the examiner's findings appeared to rely solely on the findings of the November 2012 VA examiner. Moreover, a review of the Veteran's VA treatment records indicates that he was to be reevaluated for diabetic retinopathy and glaucoma within the past two years; however, those evaluations appear to have been indefinitely rescheduled due to concerns involving the COVID-19 pandemic. See, e.g., VA treatment records dated June 2021, January 2021, August 2020, and May 2020. Accordingly, the Board finds that the evidence of record is insufficient to resolve the claim of entitlement to service connection for a bilateral eye disability. This claim must therefore be remanded in order to obtain a VA examination to address outstanding questions of diagnosis and nexus. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c)(4); see also Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (once VA undertakes the effort to provide an examination when developing a service connection claim, even if not statutorily obligated to do so, it must provide one that is adequate for purposes of the determination being made). On remand, any previously unobtained ongoing relevant medical records should be procured and associated with the Veteran's claims file. The matters are REMANDED for the following action: 1. Obtain all outstanding records of VA evaluation and/or treatment of the Veteran. Follow the procedures set forth in 38 C.F.R. § 3.159(c) with respect to requesting records from Federal facilities. All records/responses received should be associated with the claims file. 2. Schedule the Veteran for an examination to determine the nature and etiology the claimed bilateral eye disability. After examining the Veteran and reviewing the record, the examiner should provide an opinion as to the following: Is it at least as likely as not that the Veteran currently has, or has had at any point since October 2012, glaucoma and/or diabetic retinopathy. (a). As to any eye disability present during the period of the claim, the examiner must opine whether it is at least as likely as not related to an in-service injury or disease. (b). As to any eye disability present during the period of the claim, the examiner should also address whether it is at least as likely as not that the disability was caused by the service-connected diabetes mellitus? (c) If not, is it at least as likely as not that the Veteran's eye disability is aggravated (made worse as shown by comparing the current disability to medical evidence created prior to any aggravation) by service-connected diabetes mellitus? If the Veteran's eye disability is aggravated by a service-connected disability, the examiner should also indicate the extent of such aggravation by identifying the baseline level of disability. This may be ascertained by the medical evidence of record and also by the Veteran's statements as to the nature, severity, and frequency of his observable symptoms over time. K. Conner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. K. Buckley, Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.